Minnesota Greenleaf.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/ or state form with your organization’s Governing Body. Sincerely, Rick Michals, J.D. Executive Regional Operations Manager JMD An equal opportunity employer. Letter ID: 292I_Revised 04/14/2023 P r o t e c t i n g , M a i n t a i n i n g a n d I m p r o v i n g t h e H e a l t h o f A l l M i n n e s o t a n s NOTICE OF CONDITIONA LLICENSE Electronically Delivered October 22, 2025 Licensee Minnesota Greenleaf 1006 Greenwood Street East Thief River Falls ,MN 56701 RE : Conditiona lLicense Number 418316 Health Facility Identification Number (HFID )30342 Project Number(s) SL30342016 Dear Licensee: The Minnesota Department of Health (MDH) completed a survey on July 18, 2025, for the purpose of assessing compliance with state licensing statutes. Based on the survey results you were found not to be in substantial compliance with the laws pursuant to Minnesota Statutes ,Chapter 144G. As a result, pursuant to Minn. Stat. § 144G2. 0 ,Subd .1 (a), MDH is issuing a 90-day conditional license ,pending appea lunder Minn. Stat. § 144G2. 0, Subd .18. STATE CORRECTIO ONRDERS The enclosed State Form documents the state correction orders. MDH documents state correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities .The assigned tag number appears in the far left column entitled "ID Prefix Tag". The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requiremen tis not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, Subd .4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G2. 0; Leve l5: a fine of $5,000 per violation, in addtion to any enforcement mechanism authorized in § 144G.20. An equal opportunity employer. Letter ID: MX30_Revised 04/14/2023 Minnesota Greenleaf October 22, 2025 Page 2 St - 0 - 0110 - 144g.10 Subdivision 1a - Assisted Living Director License Required - $1,000.00 St - 0 - 0420 - 144g.40 Subdivision 1 - Responsibility For Housing And Services - $1,000.00 St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physica lEnvironment - $500.00 St - 0 - 1290 - 144g.60 Subdivision 1 - Background Studies Required S-S - $1,000.00 St - 0 - 1620 - 144g.70 Subd. 2 (c-E) - Initial Reviews ,Assessments A, nd Monitoring - $1,000.00 St - 0 - 1730 - 144g.71 Subd. 5 - Individualized Medication Management Plan - $1,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the total amount you are assessed is $5,500.00 You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATIO ONF ACTION TO COMPLY In acc ordanc e with Minn. Stat. § 144 G.30 , Subd .5(c), the licensee must do cume nt ac tio ns ta ken to comply with the correction orders and immediately correct any reissued orders outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: x Identify how the area(s) of noncompliance was corrected related to the resident(s)/ employee(s) identified in the correction order. x Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/ employees that may be affected by the noncompliance. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI OPNROCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued ,including the level and scope ,and any fine assesse dthrough the correction order reconsideration process .The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm REQUESTIN AG HEARING Alternatively, in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, Subd .14 and Subd .18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconsideration ,please follow the procedure outlined above. Please note that you may request a reconsideration or a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. If you request a hearing, please specify whether you are appealing the orders and fines, the Minnesota Greenleaf October 22, 2025 Page 3 imposed conditions, or both. CONDITIONA LLICENS IESSUED: MDH will issue Minnesota Greenlea fa conditional assisted living facility license for 90 calendar days from the date of this notice. At an unannounced point in time, within the 90 calendar days, MDH will conduct a follow-up survey, as defined in Minn. Stat. § 144G.30, Subd .6. Based on the results of the follow-up survey, MDH will determine if Minnesota Greenlea fis in substantia lcompliance. The following conditions apply on the conditional assisted living facility license: a. No new substantiated maltreatment allegations: If any new investigations begin in the conditional license period, and the allegations are substantiated ,MDH may pursue additional enforcement actions up to and including immediate temporary suspension and revocation of the license. b. No new admissions :Minnesota Greenlea fwill not admit any new residents under its conditional assisted living facility license until MDH removes the “no new admissions ”condition. Minnesota Greenlea fmust provide the Department: i. A list of the names and birthdates of any individuals Minnesota Greenlea fis currently in the process of admitting. These individuals will be able to continue the admittance process. ii. A list of all current residents: 1. Name and birthdate of each resident 2. Current payment source for services 3. If Elderly Waiver, the name and contact information of the care coordinator/case manager 4. If the resident is not able to make informed decisions ,the name of their representative and how to contact the representative c. Consultant: Minnesota Greenlea fwill contract with an RN to provide consultation concerning all resident(s) to whom Minnesota Greenlea fprovides licensed assisted living serv ices under the co nditio nal lic ens e. The consultant must hav e ac cess to all resident(s) receiving services from Minnesota Greenleaf .The consultant will conduct initial and ongoing evaluations of the provider. Direct resident observation may be required based on the consultant’s judgement or at the discretion of MDH. The RN must not have any affiliation with Minnesota Greenlea fand MDH must review the RNs’ credentials and approve the selection .Minnesota Greenlea fis responsible for the expense of the contract with the RN.

Finding: Inconclusive Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation: The alleged perpetrator (AP) abused the resident which resulted in a purple bruise on the resident’s left breast. The resident displayed a change in behavior by isolating more to her room and flinched during personal cares during that time. Investigative Findings and Conclusion: The Minnesota Department of Health determined abuse was inconclusive. While there is sufficient evidence showing the resident’s left breast was bruised, there is not sufficient evidence to demonstrate how it occurred nor who might be responsible. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident record, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. The investigator observed interactions between staff and residents during a recent visit to the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s Disease. The resident’s service plan included assistance with activities of living including personal cares and bathing assistance. The resident’s assessment indicated she could ambulate on her own, had poor memory and impaired decision-making skills. One morning caregivers noticed the resident had discoloration located on her left breast, which had characteristics of a new bruise. Caregivers also observed the resident flinch when approached during bathing cares and isolated herself more to her room when her routine had been to walk in the hallways. A facility incident report indicated staff members identified a bruise on the resident’s left breast with morning cares and notified the on-call nurse. A progress note later the same day indicated the bruise presented as a purple coloration on her skin. When unlicensed caregivers attempted to assist her with a shower, noticed the discoloration, and asked the resident what occurred. The same document indicated the resident said a [reference to skin color] “did it”. The medical record indicated the bruise resolved without treatment. During an interview, a nurse stated that she did not interview the resident but received the information from caregivers who assisted the resident that day. The nurse stated staff members schedules were reviewed to narrow down the staff who worked when the injury may have occurred. During an interview, an unlicensed caregiver stated the resident was jumpy and seemed to resist physical touch during shower assistance one morning. The caregiver stated she noticed the bruise, which was not there the day before. The caregiver stated that the resident said ‘the [reference to skin color] girl did it.’ The caregiver stated there were multiple females working at the facility who fit that description worked at the facility along with the AP, however the AP had worked the night before the bruise was identified. During interview, a manager stated that the injury looked like a pinch bruise. During interview with this investigator, the resident had difficulty recalling person, place and time questions and was unable to recall any incident in which the bruise could have occurred. During interview, a family member stated he was not aware of the bruise found on the resident or had he heard there was an allegation of any suspected abuse. The Minnesota Department of Health determined abuse was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Abuse: Minnesota Statutes section 626.5572, subdivision 2. "Abuse" means: (b) Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; or (3) use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. (c) Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. (d) The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's will to perform services for the advantage of another. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: No, the AP declined an interview with the investigator. Action taken by facility: The facility reported the matter to law enforcement. The AP no longer works at the facility. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 03/27/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30342 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 GREENWOOD STREET EAST MINNESOTA GREENLEAF THIEF RIVER FALLS, MN 56701 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On March 6, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL303425200C/#HL303428422M and HL303424361C/#HL303428142M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1OP111 If continuation sheet 1 of 1

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation: The facility neglected the resident when it failed to adequately assess and monitor the resident’s lower leg injury resulting in swelling, redness and pain. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. A facility nurse looked at the injury and documented the resident stated he bumped his left lower leg resulting in a large purple bruise. The resident did not choose to have it evaluated at that time, so the nurse scheduled the next available appointment with the resident’s medical provider. The resident did not alert staff when the wound worsened until another agency nurse made a visit and the resident was then sent in for a medical evaluation. The investigator conducted interviews with facility staff members, including administrative staff and nursing staff. The investigation included review of the resident record, facility incident reports, staff schedules, related facility policy and procedures Also, the investigator observed residents and staff during routine activities during a recent visit to the facility. The resident resided in an assisted living facility. The resident’s diagnoses included diabetes, congestive heart failure, atrial fibrillation and lymphedema. The resident’s care plan indicated he was independent with personal cares, hygiene and mobility. The care plan also indicated the resident’s lower legs were fragile, discolored, bruised easily and he would ask for assistance if he noticed any open areas that needed assessment. The resident’s assessment indicated the resident was oriented and could verbalize his needs. A concern arose the resident had an injury to his leg that had become red, very swollen, blistered and painful to the touch. The report indicated the injury was not monitored and the resident was not provided pain medication for the injury. During an interview, a facility nurse stated the resident brought the injury to her attention and it appeared to be a bruise. The nurse stated it was not red with no evidence of a clot. She stated follow-up options were discussed at that time with the resident, who did not want it to be immediately evaluated, and she made the soonest appointment with his medical provider that was available. She stated the resident agreed to go in sooner if it worsened. During interview, a second facility nurse stated she did not receive any concerns from staff or the resident that the injury had worsened or that it needed immediate attention. During interview, the resident stated he had fallen but could not remember when it happened. The resident said he thought the injury occurred then and the nurse looked at it. The resident stated he did not think it was bad at the time and never really told anyone about it. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: No action taken. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 03/27/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30342 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 GREENWOOD STREET EAST MINNESOTA GREENLEAF THIEF RIVER FALLS, MN 56701 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On March 6, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL303425200C/#HL303428422M and HL303424361C/#HL303428142M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1OP111 If continuation sheet 1 of 1

STATE LICENSING COMPLIANCE REPORT Report #: HL303421222C Date Concluded: November 3, 2023 Name, Address, and County of Facility Investigated: Minnesota Greenleaf 1006 Greenwood Street East Thief River Falls, MN 56701 Pennington County Facility Type: Assisted Living Facility with Evaluator’s Name: Angela Vatalaro, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call website, please see the attached state form. PRINTED: 11/06/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30342 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 GREENWOOD STREET EAST MINNESOTA GREENLEAF THIEF RIVER FALLS, MN 56701 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On October 31, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL303421222C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 MHOC11 If continuation sheet 1 of 1